If you are interested in obtaining a copy of your medical record(s), please print and complete the Authorization for Release of Protected Health Information form.
Download the Authorization for Release of Protected Health Information form:
Upon completion, you may fax or mail, your Authorization to address on top of the form.
In order to verify your identification and validate your authorization, we require that you include a legible copy of a valid photo I.D. (e.g., driver’s license, military I.D. or state I.D.), and a telephone number. Per Florida statute, there may be a charge for providing the copy of $0.25 per page.
Please allow up to 10 business days from the date of your request to process.
3301 Executive Way
Miramar, FL 33025
Phone: (866) 463-7439
Fax: (855) 446-6008
Mon - Fri: 9:00am - 4:30pm
For further information or assistance with the Authorization form, please call (866) 463-7439